Abstract
Medical trainee burnout is associated with poor quality care and attrition. Medical students in sexual minority groups report fear of discrimination and increased mistreatment, but the association between sexual orientation, burnout, and mistreatment is unknown. To evaluate whether medical student burnout differs by sexual orientation and whether this association is mediated by experiences of mistreatment. This cross-sectional study surveyed US medical students graduating from Association of American Medical Colleges (AAMC)-accredited US allopathic medical schools who responded to the AAMC graduation questionnaire in 2016 and 2017. Statistical analyses were performed from March 15, 2019, to July 2, 2020, and from November 20 to December 9, 2020. Burnout was measured using the Oldenburg Burnout Inventory for Medical Students, and sexual orientation was categorized as either heterosexual or lesbian, gay, or bisexual (LGB). Logistic regression models were constructed to evaluate the association between sexual orientation and experiencing burnout (defined as being in the top quartile of exhaustion and disengagement burnout dimensions) and to test the mediating association of mistreatment. From 2016 to 2017, 30 651 students completed the AAMC Graduation Questionnaire, and 26 123 responses were analyzed. Most respondents were younger than 30 years (82.9%) and White (60.3%). A total of 13 470 respondents (51.6%) were male, and 5.4% identified as LGB. Compared with heterosexual students, a greater proportion of LGB students reported experiencing mistreatment in all categories, including humiliation (27.0% LGB students vs 20.7% heterosexual students; P < .001), mistreatment not specific to identity (17.0% vs 10.3%; P < .001), and mistreatment specific to gender (27.3% vs 17.9%; P < .001), race/ethnicity (11.9% vs 8.6%; P < .001), and sexual orientation (23.3% vs 1.0%; P < .001). Being LGB was associated with increased odds of burnout (adjusted odds ratio, 1.63 [95% CI, 1.41-1.89]); this association persisted but was attenuated after adjusting for mistreatment (odds ratio, 1.36 [95% CI, 1.16-1.60]). The odds of burnout increased in a dose-response manner with mistreatment intensity. Lesbian, gay, or bisexual students reporting higher mistreatment specific to sexual orientation had and 8-fold higher predicted probability of burnout compared with heterosexual students (19.8% [95% CI, 8.3%-31.4%] vs 2.3% [95% CI, 0.2%-4.5%]; P < .001). Mediation analysis showed that mistreatment accounts for 31% of the total association of LGB sexual orientation with overall burnout (P < .001). This study suggests that LGB medical students are more likely than their heterosexual peers to experience burnout, an association that is partly mediated by mistreatment. Further work is needed to ensure that medical schools offer safe and inclusive learning environments for LGB medical students.
Highlights
Burnout is a long-term reaction to stress characterized by emotional exhaustion, depersonalization, cynicism, and feelings of decreased personal accomplishment
Gay, or bisexual students reporting higher mistreatment specific to sexual orientation had and 8-fold higher predicted probability of burnout compared with heterosexual students (19.8% [95% CI, 8.3%-31.4%] vs 2.3% [95% CI, 0.2%4.5%]; P < .001)
Gay, or bisexual medical students have reported concealing their sexual identity during medical school for fear of discrimination[23] as well as increased depression, anxiety, and low self-rated health compared with heterosexual medical students.[24]
Summary
Burnout is a long-term reaction to stress characterized by emotional exhaustion, depersonalization, cynicism, and feelings of decreased personal accomplishment. Causes of burnout are multifactorial and include competing time demands, strained finances, and unattainable expectations of medical training.[9,11,14] Mistreatment is a important factor in the development of burnout.[15] Surveys of medical students have shown an association between mistreatment and burnout and a dose-response association between frequency of mistreatment and risk of burnout.[15] Mistreatment and discrimination have been shown to be negatively associated with the medical education of trainees in minority racial/ethnic groups (ie, Hispanic/Latinx, non-Hispanic Black, and non-Hispanic Asian individuals); some studies have shown lower rates of burnout among physicians and medical trainees in minority racial/ethnic groups.[16,17] Previous research has begun to investigate individual and institutional factors associated with medical student burnout broadly; to our knowledge, these factors have not been studied among lesbian, gay, or bisexual (LGB) medical students. These findings suggest that LGB physicians and physicians in training may be subject to unique stressors that are associated with their ability to remain in the health care workforce
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